Non-emergency Caesarean Section Research Articles

Quadratus Lumborum Block and Transversus Abdominis Plane Block in Non-emergency Cesarean Delivery: A Systematic Review and Meta-analysis

PurposeInvestigate the analgesic efficacy of quadratus lumborum (QL) block versus transversus abdominis plane (TAP) block in postoperative pain management in nonemergent cesarean section. DesignSystematic review with meta-analysis. MethodsPubMed, Cochrane, CINAHL, Google Scholar, and gray literature were searched for evidence. Only randomized controlled trials examining the effects of QL and TAP block for nonemergent cesarean delivery were included. Mean difference (MD) was used to estimate continuous outcomes with appropriate effect models. The quality of evidence was rated using the Risk of Bias and Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) system. FindingsSix studies involving 543 parturients were included. Compared to the TAP block, the cumulative 24-hour pain score at rest (MD, −0.60; 95% CI, −1.03 to −0.17; P = .007) and during activity (MD, −1.05; 95% CI, −1.54 to −0.56; P < .0001) were significantly lower in QL block. Time to the first analgesic rescue (MD, 21.67; 95% CI, −18.58 to 61.91; P = .29) and opioid consumption (MD, −1.96; 95% CI, −4.59 to 0.66; P = .14) were similar in both groups. No difference was found in the incidence of postoperative nausea and vomiting and sedation. However, patients treated with QL block reported higher patient satisfaction scores. ConclusionsThere is limited evidence to suggest that QL block is superior to TAP block for postoperative pain management in nonemergent cesarean delivery. The study limitations must be considered when extrapolating the review’s findings to clinical practice.

Comparing the efficacy of different doses of intrathecal dexmedetomidine on hemodynamic parameters and block characteristics with ropivacaine spinal anesthesia for cesarean section: A double-blind, randomized clinical trial

Aims: This study aimed to assess the dose-related efficacy of intrathecal dexmedetomidine (DEX) on hemodynamic parameters and block characteristics following ropivacaine (ROP) spinal anesthesia (SA) for cesarean section (CS).Methods: This was a double-blind trial conducted on four groups namely D2.5, D5, D7.5, and placebo. One hundred and twenty patients scheduled for nonemergency CS under SA were recruited and randomized into four groups. The first to fourth groups received 2.5 μg, 5 μg, and 7.5 μg of intrathecal DEX and 1.5 mL normal saline, respectively, in addition to ROP for SA. Blood pressure (BP), heart rate (HR), arterial blood saturation, sensory motor block, and pain score were recorded.Results: The lowest BP/HR was observed in D7.5 group (P < 0.05). Moreover, the onset and duration of sensory motor block were shorter (P = 0.0001) and showed the lowest level of pain (P = 0.0001) in D7.5 group. Decrease in BP, HR, and pain score was observed with increasing dose of DEX, whereas the onset of sensory motor block and the time to achieve sensory motor block to ≥T6 declined with increasing the dose of DEX.Conclusion: The 7.5-μg intrathecal DEX is recommended to use for stabling the hemodynamic parameters and block characteristics following ROP SA for CS. However, likely complications such as fall in both HR and BP should be taken into account simultaneously.

Breastfeeding and Birth mode: comparative analysis between elective and in-labor caesarean section

Abstract Introduction Evidence in literature suggests that the outcomes of children born by in-labor non-emergency caesarean section (CS) are better if compared to those born by programmed CS. The aim of this work was to evaluate impact of type of CS on neonatal outcomes and breastfeeding. Materials and methods The cross-sectional study was performed in the Siena province (hospital of Siena and Poggibonsi) during the period January-December 2015. All females that gave birth by CS were included, except those that had emergency CS from severe medical indication (pre-eclampsia/eclampsia, fetal distress, intrauterine growth retardation, etc) or due to multiple pregnancy. The sample was divided in two groups (programmed CS/CS in the presence of labor). The outcome variables were: necessity of hospitalization in neonatal intensive therapy unit (NITU) or resuscitation; weight loss after birth (%), hours passed between birth and first attack to the breast, type of breastfeeding at discharge (exclusive/mixed). The statistical analysis was performed with Stata 12. Results In total 446 females were included (53.6% programmed CS). Any association between the type of CS and admission to NITU or resuscitation was observed. Among the newborns born by CS in the presence of labor, there was a greater proportion of babies who attached to the breast immediately after birth (82% vs. 71%; p &amp;lt; 0.05) and also those exclusively breastfed at the moment of discharge (71% vs. 60%; p &amp;lt; 0.05). The weight loss was lower in babies born by CS in the presence of labor (8%±1.8; 95% CI 7.7%-8.2% vs. 8.53%±1.7%; 95% CI: 8.3%-8.8%; p &amp;lt; 0.05). Conclusions Our study confirmed the negative impact of the CS in the absence of labor on the breastfeeding initiation, probably due to incomplete activation of neuroendocrine mechanisms (release of oxytocin; etc). The CS in the presence of labor is more stressful from the organizational point of view, but it helps promotion of health through the facilitation of breastfeeding. Key messages In-labor non-emergency caesarean section is more physiological and helps to initiate and maintain breastfeeding. The CS in the presence of labor is more stressful from the organizational point of view, but it helps promotion of health through the facilitation of breastfeeding.

The Not-so-Sterile Womb: Evidence That the Human Fetus Is Exposed to Bacteria Prior to Birth.

The human microbiome includes trillions of bacteria, many of which play a vital role in host physiology. Numerous studies have now detected bacterial DNA in first-pass meconium and amniotic fluid samples, suggesting that the human microbiome may commence in utero. However, these data have remained contentious due to underlying contamination issues. Here, we have used a previously described method for reducing contamination in microbiome workflows to determine if there is a fetal bacterial microbiome beyond the level of background contamination. We recruited 50 women undergoing non-emergency cesarean section deliveries with no evidence of intra-uterine infection and collected first-pass meconium and amniotic fluid samples. Full-length 16S rRNA gene sequencing was performed using PacBio SMRT cell technology, to allow high resolution profiling of the fetal gut and amniotic fluid bacterial microbiomes. Levels of inflammatory cytokines were measured in amniotic fluid, and levels of immunomodulatory short chain fatty acids (SCFAs) were quantified in meconium. All meconium samples and most amniotic fluid samples (36/43) contained bacterial DNA. The meconium microbiome was dominated by reads that mapped to Pelomonas puraquae. Aside from this species, the meconium microbiome was remarkably heterogeneous between patients. The amniotic fluid microbiome was more diverse and contained mainly reads that mapped to typical skin commensals, including Propionibacterium acnes and Staphylococcus spp. All meconium samples contained acetate and propionate, at ratios similar to those previously reported in infants. P. puraquae reads were inversely correlated with meconium propionate levels. Amniotic fluid cytokine levels were associated with the amniotic fluid microbiome. Our results demonstrate that bacterial DNA and SCFAs are present in utero, and have the potential to influence the developing fetal immune system.

Efficacy of continuous in-wound infusion of levobupivacaine and ketorolac for post-caesarean section analgesia: a prospective, randomised, double-blind, placebo-controlled trial

BackgroundIn-wound catheters for infusion of local anaesthetic for post-caesarean section analgesia are well tolerated in parturients. Few studies have examined continuous in-wound infusion of a combination of local anaesthetic and non-steroidal anti-inflammatory drug for post-caesarean section analgesia. This single centre study evaluated post-operative analgesic efficacy and piritramide-sparing effects of continuous in-wound infusion of either local anaesthetic or non-steroidal anti-inflammatory agent, or the combination of both, versus saline placebo, when added to systemic analgesia with paracetamol.MethodsAfter National Ethical Board approval, 59 pregnant women scheduled for non-emergency caesarean section were included in this prospective, randomised, double-blind, placebo-controlled study. The parturients received spinal anaesthesia with levobupivacaine and fentanyl. Post-operative analgesia to 48 h included paracetamol 1000 mg intravenously every 6 h, with the studied agents as in-wound infusions. Rescue analgesia with piritramide was available as needed, titrated to 2 mg intravenously. Four groups were compared, using a subcutaneous multi-holed catheter connected to an elastomeric pump running at 5 mL/h over 48 h. The different in-wound infusions were: levobupivacaine 0.25% alone; ketorolac tromethamine 0.08% alone; levobupivacaine 0.25% plus ketorolac tromethamine 0.08%; or saline placebo. The primary outcome was total rescue piritramide used at 24 h and 48 h post-operatively, under maintained optimal post-caesarean section analgesia.ResultsCompared to placebo in-wound infusions, ketorolac alone and levobupivacaine plus ketorolac in-wound infusions both significantly reduced post-operative piritramide consumption at 24 h (p = 0.003; p < 0.001, respectively) and 48 h (p = 0.001; p < 0.001). Compared to levobupivacaine, levobupivacaine plus ketorolac significantly reduced post-operative piritramide consumption at 24 h (p = 0.015) and 48 h (p = 0.021). For levobupivacaine versus ketorolac, no significant differences were seen for post-operative piritramide consumption at 24 h and 48 h (p = 0.141; p = 0.054).ConclusionContinuous in-wound infusion with levobupivacaine plus ketorolac provides greater opioid-sparing effects than continuous in-wound infusion with levobupivacaine alone.Trial registrationGerman Clinical Trials Register: retrospectively registered on 30 July, 2014, DRKS 00006559.

The effects of capsaicin ointment application to the K-K9 acupressure point on nausea and vomiting during cesarean section under spinal anesthesia

Background: Nausea and vomiting are among the most important and the most common intraoperative and postoperative complications. Objective: This study aimed to determine the effects of capsaicin ointment application to the K-K9 acupressure point on intraoperative and postoperative nausea and vomiting associated with cesarean section (CS) under spinal anesthesia. Methods: This double-blind three-group randomized controlled trial was conducted on 120 women who referred to Ommolbanin Hospital, Mashhad, Iran, to undergo nonemergency CS under spinal anesthesia. Women were randomly allocated to three groups to receive capsaicin ointment on the K-K9 point (intervention group), capsaicin ointment on the K-D2 point (control group), and Vaseline ointment on the K-K9 point (placebo group). Nausea, vomiting, and retching were assessed at five time points, namely during and 30, 60, 90, and 120 min after CS. Moreover, the need for antiemetic medications was also assessed in all three groups. The data were analyzed through running the one-way analysis of variance, the Kruskal–Wallis, the Friedman, and the Chi-square tests. Results: There were no significant differences among the groups, respecting the scores of nausea, vomiting, and retching at different measurement time points (P > 0.05). However, the number of women who needed antiemetic medication in the intervention group (11) was significantly less than the control (22) and the placebo (15) groups (P = 0.04). Conclusion: Capsaicin ointment application to the K-K9 acupressure point is an easy-to-use noninvasive method for significantly reducing the need for antiemetic medications during and after CS under spinal anesthesia.

Effect of Intra-Operative Glove-Changing During Cesarean on Post-Op Complications: A Randomized Controlled Trial [12OP

INTRODUCTION: An increasing body of literature suggests that vaginal floral bacteria contribute to post-operative infectious morbidity when introduced to normally sterile environments during cesarean section. Surgeon's gloves, exposed to the lower genitourinary tract during delivery of an infant, may be an important vehicle of bacteria to the abdominal wall. Changing gloves during cesarean prior to abdominal wall closure may decreased bacterial transfer to the wound bed and therefore the incidence of wound complications following cesarean section. METHODS: This is a randomized controlled trial. Women undergoing non-emergent cesarean section were randomized to control conditions or intra-operative glove-changing, which entailed surgeons changing outer sterile gloves prior to abdominal closure. The primary outcome is composite wound complications, defined as the occurrence of seroma, hematoma, wound infection, skin separation of at least 1cm, or other incisional separation or abnormality requiring a bedside procedure Enrollment of 554 patients provides 80% power to detect a 50% reduction in the primary outcome from the approximately 15% incidence noted in the first 100 control subjects studied during a planned interim analysis. RESULTS: Of the first 409 patients analyzed, a significant reduction in composite wound complications is observed in the glove-changing group (11/185, 5.9%) compared to the control group (29/224, 12.9%), with p-value 0.018. At time of this submission, there are 145 subjects remaining to analyze, estimated to complete by December 2016. CONCLUSION: Preliminary analysis of this nearly completed randomized controlled trial indicates a trend toward reduction of composite wound complications following cesarean section when gloves are changed prior to abdominal closure.

The Effects of Abdominal Binder on Wound Healing and Consumed Pain Medications After Cesarean Section: A Randomized Control Trial

Background: Wound complications and pain are major causes of morbidity after cesarean section (CS). Although medications are safe for use by mothers after CS, many females prefer non-pharmaceutical methods. An abdominal binder is a complementary therapy, commonly used post-major abdominal surgery. Objectives: There is limited evidence about the effect of abdominal binders. The aim of this study was to investigate the effects of an abdominal binder on wound healing and consumed pain medication. Methods: This randomized controlled trial included 178 females, who had undergone non-emergency CS at 1 of the 3 hospitals in Gonbad-e Kavus, and Golestan, northeast of Iran. In the intervention group, patients were administered abdominal binders, in addition to routine care. The binder was used for 2 days after the patient was admitted to the surgery ward. The control group received routine care. We used the demographic data questionnaire, questionnaire for cataloguing analgesic medications taken by participants (each 6 hours after CS), and Redness, Edema, Ecchymosis, Discharge, Approximation of wound edges (REEDA) scale for assessment of wound healing. The participants provided their written consent for participation in this study. Results: The mean (SD) age of the participants was 26.3 (5) years. Mean (SD) REEDA score was 0.4 (0.5) in the intervention group and 0.5 (0.8) in the control group. The median (quartile 25-75) REEDA score was 0 (0-1) in both groups. Mean REEDA scores did not differ significantly between the 2 groups (P = 0.724). Significant differences were observed in the approximation of wound edges in the intervention group 5 days post-CS (P = 0.007). Administered analgesic medications did not differ significantly between the 2 groups (at 6 hours in suppository, and 6 and 24 hours post-intervention in intramuscular of injection narcotics). Significantly fewer analgesic medications were administered in the intervention group when compared with the control group (P = 0.001). Satisfaction did not differ significantly between the 2 groups (P= 0.443). Conclusions: In this study, the abdominal binder was effective in pain medication consumption at some intervals. However, it had no healing effect on CS scars. © 2017, Iranian Red Crescent Medical Journal.

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Anesthetic practice for Caesarean section and factors influencing anesthesiologists' choice of anesthesia: a population-based study.

We examined the change in anesthetic practice for Caesarean section (CS) during the past decade and determined factors influencing anethesiologists' decisions. The cases were identified from data retrieved from Longitudinal Health Insurance Database released by the Taiwan National Health Research Institute in 2008. Trend analysis was performed using logistic regression models. The decision tree analysis was performed using the chi-squared automatic interaction detector method and multivariable logistic regression analysis was performed to identify predictors of general anesthesia. A total of 25,606 women undergoing CS were studied. Logistic regression analyses revealed an upward trend of spinal anesthesia from 2000 to 2008 [57.8-67.5%, adjusted odds ratio (OR) = 1.06, 95% confidence interval (CI) = 1.05-1.07, P < 0.001] and a decreasing trend across time for both general and epidural anesthesia (5.5-3.9% and 36.7-28.6%; both OR < 1, both P < 0.001). Patterns of change in anesthetic practice across time for emergency and non-emergency CS were similar (all P < 0.05). Our data further demonstrated that early or threatened labor, a history of preeclampsia, antepartum hemorrhage, emergency CS, and previous CS were important predictors that influenced the anesthesiologists' choice of general anesthesia versus neuraxial anesthesia for women undergoing CS. Spinal anesthesia was the most common mode of anesthesia for CS deliveries in Taiwan during the past decade. Early or threatened labor, antepartum hemorrhage, emergency CS, previous CS, and preeclampsia are significant determinants of general anesthesia in CS deliveries.

Spinal anaesthesia for caesarean section: an ultrasound comparison of two different landmark techniques

BackgroundSpinal anaesthesia performed at levels higher than the L3–4 intervertebral space may result in spinal cord injury. Our aim was to establish a protocol to reduce the chance of spinal anaesthesia performed at or above L2–3. MethodsOne hundred and ten consenting patients at 32weeks of gestation or greater scheduled for non-emergency caesarean section under spinal anaesthesia were randomly allocated to have needle insertion performed at an intervertebral space determined by one of two landmark techniques. In Group A, if the intercristal line intersected an intervertebral space, this space was selected or if the intercristal line intersected a spinous process the space immediately above was selected. In Group B, if the intercristal line intersected an intervertebral space or a spinous process, the intervertebral space immediately below was chosen. The actual intervertebral space chosen was identified using ultrasound by a blinded investigator. ResultsIn Group A, an intervertebral space at or above L2–3 was marked in 25 (45.5%) patients compared with 4 (7.3%) in Group B (P <0.001). In 5/55 (9.1%) patients in Group A, the intervertebral space initially chosen was L1–2 whereas this occurred in no patient in Group B. There was no difference between groups in number of needle passes or attempts, onset of block at 5, 10 and 15min or need for rescue analgesia. ConclusionOur data suggest that when performing spinal anaesthesia in pregnant patients, if the intercristal line intersects an intervertebral space then the space below should be chosen and if the intercristal line intersects a spinous process then the interspace below should be chosen. This will reduce the incidence of spinal anaesthesia performed at or above L2–3.

Measuring Coverage in MNCH: Validating Women’s Self-Report of Emergency Cesarean Sections in Ghana and the Dominican Republic

BackgroundCesarean section is the only surgery for which we have nearly global population-based data. However, few surveys provide additional data related to cesarean sections. Given weaknesses in many health information systems, health planners in developing countries will likely rely on nationally representative surveys for the foreseeable future. The objective is to validate self-reported data on the emergency status of cesarean sections among women delivering in teaching hospitals in the capitals of two contrasting countries: Accra, Ghana and Santo Domingo, Dominican Republic (DR).Methods and FindingsThis study compares hospital-based data, considered the reference standard, against women’s self-report for two definitions of emergency cesarean section based on the timing of the decision to operate and the timing of the cesarean section relative to onset of labor. Hospital data were abstracted from individual medical records, and hospital discharge interviews were conducted with women who had undergone cesarean section in two hospitals. The study assessed sensitivity, specificity, and positive predictive value of responses to questions regarding emergency versus non-emergency cesarean section and estimated the percent of emergency cesarean sections that would be obtained from a survey, given the observed prevalence, sensitivity, and specificity from this study. Hospital data were matched with exit interviews for 659 women delivered via cesarean section for Ghana and 1,531 for the Dominican Republic. In Ghana and the Dominican Republic, sensitivity and specificity for emergency cesarean section defined by decision time were 79% and 82%, and 50% and 80%, respectively. The validity of emergency cesarean defined by operation time showed less favorable results than decision time in Ghana and slightly more favorable results in the Dominican Republic.ConclusionsQuestions used in this study to identify emergency cesarean section are promising but insufficient to promote for inclusion in international survey questionnaires. Additional studies which confirm the accuracy of key facility-based indicators in advance of data collection and which use a longer recall period are warranted.

High caesarean section rate in rural China: Is it related to health insurance (New Co-operative Medical Scheme)?

The epidemic of Caesarean section (CS) is worldwide, and it has been argued that it is mainly due to non-medical factors, including healthcare financing patterns. We investigated the use of CS in rural China and the related factors, particularly health insurance in the form of the New Co-operative Medical Scheme introduced in 2003.A cross-sectional survey of women who gave birth in 2008–2009 was conducted in five rural counties in central and western China. Of the 5049 new mothers, 73% were interviewed. The association between health insurance coverage and self-reported CS (divided into emergency and non-emergency CS) were examined by cross-tabulation and logistic regression, adjusting for maternal age, education, occupation, household income, previous abortions, parity and type of birth health facility. We found that 46% of all births (3550) were CSs, with 13% having an emergency and 33% a non-emergency CS. Women reported that half of the non-emergency CSs were recommended by a doctor and half were requested by themselves. In those counties with mid-range CS rates (28%–63%), health insurance coverage was associated with having CS, and particularly with having non-emergency CS. In those counties with the highest (82%) and lowest (13%) rate, there was no statistically significant association. The findings suggest that health insurance coverage may have facilitated the overuse of CS. Further studies are needed to develop appropriate interventions to reduce non-medically indicated CS, focussing on payment mechanisms, healthcare provider practice patterns, and maternal requests.

Mandatory second opinion to reduce rates of unnecessary caesarean sections in Latin America: a cluster randomised controlled trial

Latin America has a high rate of caesarean sections. We tested the hypothesis that a hospital policy of mandatory second opinion, based on the best existing scientific evidence, reduces the hospital caesarean section rate by 25%, without increasing maternal and perinatal morbidity and mortality. 36 hospitals in Argentina (18), Brazil (eight), Cuba (four), Guatemala (two), and Mexico (four), were randomly assigned to intervention or control in a matched pair design. All physicians in the intervention hospitals deciding a non-emergency caesarean section had to follow a policy of mandatory second opinion. The primary outcome was the overall caesarean section rate in the hospitals after a 6-month implementation period. We also assessed women's satisfaction with labour and delivery care and physicians'acceptance of the second opinion policy. A total of 34 hospitals attending 149?276 deliveries were randomised and completed the protocol. The mandatory second opinion policy was associated with a small but significant reduction in rates of caesarean section (relative rate reduction 7.3%; 95% CI 0.2-14.5), mostly in intrapartum sections (12.6%; 0.6-24.7). Other maternal and neonatal outcomes and women's perceptions and satisfaction with the process of care were similarly distributed between the groups. In hospitals applying this policy of second opinion, 22 intrapartum caesarean sections could be prevented per 1000 deliveries, without affecting maternal or perinatal morbidity, and without affecting mothers' satisfaction with the care process.

Comparing the efficacy of prophylactic metoclopramide, ondansetron, and placebo in cesarean section patients given epidural anesthesia

Study Objective: To compare the relative efficacy of prophylactic metoclopramide, ondansetron, and placebo in nonemergent cesarean section patients given epidural anesthesia intraoperatively and for the first 24-hour period after delivery. Design: Randomized, double blind, placebo-controlled study. Setting: Inpatient obstetric unit at a university hospital center. Patients: 164 nonemergent cesarean section patients given epidural anesthesia. Intervention: At time of umbilical cord clamp, patients received intravenously (IV) either 4 mg ondansetron (Group O) or 10 mg metoclopramide (Group M) or 10 mL normal saline (Group P). Measurements and main results: Episodes and severity of nausea and vomiting, rescue antiemetic requirement, patient satisfaction, and side effects were recorded. The frequency of intraoperative nausea were 24%, 43%, and 57% for Group O, Group M, and Group P, respectively (p < 0.03). The frequency of nausea for the 24-hour study period were 26%, 51% and 71% for Groups O, M, and P respectively (p < 0.03). The frequency of intraoperative and postoperative vomiting were similar between Group O and Group M, but significantly higher in Group P (p < 0.05). Overall patient satisfaction was highest in Group O compared with Groups P and M (p < 0.05). Maximum analog sedation score was higher in Group M compared to Groups O and P (p < 0.05). Conclusions: In cesarean section patients given epidural anesthesia, prophylactic ondansetron, 4 mg IV, is more efficacious and has a higher patient satisfaction than that with metoclopramide, 10 mg IV, or placebo in preventing nausea and achieving complete responses during intraoperative period and the first 24-hour postdelivery period. However, there is no difference between ondansetron and metoclopramide in reducing frequency of vomiting. Prophylactic ondansetron 4 mg IV is more effective in preventing nausea than vomiting.

Intravenous Remifentanil: Placental Transfer, Maternal and Neonatal Effects

KAN, RANDALL E.; HUGHES, SAMUEL C.; ROSEN, MARK A.; KESSIN, CHARLIZE; PRESTON, PAUL G.; LOBO, ERROL P. Author Information

Prevention of maternal hypotension by epidural administration of ephedrine sulfate during lumbar epidural anesthesia for cesarean section

OBJECTIVE: Our purpose was to determine whether epidural administration of ephedrine sulfate simultaneously with induction of lumbar epidural anesthesia for nonemergency cesarean section reduces the incidence of maternal hypotension. STUDY DESIGN: In a double-blinded, placebo-controlled trial, 50 normotensive, nonlaboring, American Society of Anesthesiologists' class I or II women with term, uncomplicated, singleton pregnancies were randomly assigned to have normal saline solution or ephedrine sulfate administered epidurally and coincidentally with induction of lumbar epidural anesthesia for nonemergency cesarean section. All subjects were prehydrated with 25 ml/kg crystalloid and placed in supine position on a 15-degree, right-sided wedge before and after induction. Serial blood pressures were compared with baseline blood pressures, chosen as the average of three preinduction blood pressures. Hypotension was defined as a decline in systolic blood pressure to ≤90 mm Hg or ≤70% of baseline. Differences between groups were analyzed by Fisher's Exact Test. Significance was determined at p < 0.05. RESULTS: The incidence of hypotension in the control group was 24%, which was not significantly different from the incidence of 32% in the treated group. CONCLUSION: Prophylactic epidural administration of ephedrine sulfate does not reduce the incidence of maternal hypotension after lumbar epidural anesthesia for nonemergency cesarean section. (Am J Obstet Gynecol 1996;175:985-90.)

Spinal Versus Epidural Anesthesia for Cesarean Section

Spinal anesthesia recently has gained popularity for elective cesarean section.Our anesthesia service changed from epidural to spinal anesthesia for elective cesarean section in 1991. To evaluate the significance of this change in terms of time management, costs, charges, and complication rates, we retrospectively reviewed the charts of patients who had received epidural (n = 47) or spinal (n = 47) anesthesia for nonemergent cesarean section. Patients who received epidural anesthesia had significantly longer total operating room (OR) times than those who received spinal anesthesia (101 +/- 20 vs 83 +/- 16 min, [mean +/- SD] P < 0.001); this was caused by longer times spent in the OR until surgical incision (46 +/- 11 vs 29 +/- 6 min, P < 0.001). Length of time spent in the postanesthesia recovery unit was similar in both groups. Supplemental intraoperative intravenous (IV) analgesics and anxiolytics were required more often in the epidural group (38%) than in the spinal group (17%) (P < 0.05). Complications were noted in six patients with epidural anesthesia and none with spinal anesthesia (P < 0.05). Average per-patient charges were more for the epidural group than for the spinal group. Although direct cost differences between the groups were negligible, there were more substantial indirect costs differences. We conclude that spinal block may provide better and more cost effective anesthesia for uncomplicated, elective cesarean sections. (Anesth Analg 1995;80:709-12)

Spinal Versus Epidural Anesthesia for Cesarean Section

Spinal anesthesia recently has gained popularity for elective cesarean section. Our anesthesia service changed from epidural to spinal anesthesia for elective cesarean section in 1991. To evaluate the significance of this change in terms of time management, costs, charges, and complication rates, we retrospectively reviewed the charts of patients who had received epidural (n = 47) or spinal (n = 47) anesthesia for nonemergent cesarean section. Patients who received epidural anesthesia had significantly longer total operating room (OR) times than those who received spinal anesthesia (101 +/- 20 vs 83 +/- 16 min, [mean +/- SD] P < 0.001); this was caused by longer times spent in the OR until surgical incision (46 +/- 11 vs 29 +/- 6 min, P < 0.001). Length of time spent in the postanesthesia recovery unit was similar in both groups. Supplemental intraoperative intravenous (i.v.) analgesics and anxiolytics were required more often in the epidural group (38%) than in the spinal group (17%) (P < 0.05). Complications were noted in six patients with epidural anesthesia and none with spinal anesthesia (P < 0.05). Average per-patient charges were more for the epidural group than for the spinal group. Although direct cost differences between the groups were negligible, there were more substantial indirect costs differences. We conclude that spinal block may provide better and more cost effective anesthesia for uncomplicated, elective cesarean sections.

Effects of Unanticipated Cesarean Section on Mothers, Infants, and Their Interaction in the First Month of Life

The impact of an unanticipated primary cesarean section on the mother, on the infant, and on their interaction was studied during the perinatal period and at 1 month following delivery. Thirty-four mother-infant pairs participated in the study. Fourteen subjects delivered by nonelective, nonemergency cesarean section. Twenty mothers, who delivered vaginally, served as the controls. All subjects had attended a series of prepared childbirth classes. Maternal questionnaire and infant observational data were collected on day 2 and on day 30. Mother-infant interactions in teaching and play sessions were assessed on day 30. The cesarean group was found to have a higher number of obstetrical complications, an increased incidence of maternal depression, and a more difficult convalescence. Previous experience with children emerged as an important mediating variable in the analysis of maternal affective status. No infant behavioral differences were detected as a function of mode of delivery. The discussion highlights the interventions that can be utilized to minimize the negative emotional consequences for women who deliver by cesarean section.